- Email: [email protected]
AFTER NORMANSFIELD—WHAT NEXT?
918 of mental-handicap hospitals may seem less pressing managers then the clamorous demands of the acute sector. Thirdly, the managers may be actively unsympathetic to the needs of the mental-handicap services, which may be regarded as outside the N.H.S. mainstream, and as providing a poor cost-benefit return. Fourthly, the managers working solely in the mental handicap sector may be less competent than others, and therefore may be unsuccessful in obtaining a proper share of resources, and in commanding the attention of upper manage-
problems to
Points of View
AFTER NORMANSFIELD—WHAT NEXT?
ment.
JACK BAVIN Twyver Unit, Coney Hill Hospital,
Gloucester GL4
7QJ
The last three factors seem to be all-important. In this where a huge effort needs to be made to provide and maintain an acceptable standard of care and treatment, the endeavours of middle and top management are crucial: nothing but a major input of managerial talent and of money will do anything but scratch the surface of the problem.
sphere, THE Normansfield Report! has not received the debate it merits. It is the latest in a series of reports documenting medical, nursing, and administrative failure to deliver a tolerable standard of treatment to longstay populations of mentally handicapped people. Normansfield presents us with a picture of a National Health Service hospital with a demoralised staff providing minimal services to keep alive in a degrading state a number of helpless handicapped people-a process which ten years ago I termed social euthanasia.2 The remedies which have been proposed and implemented raise standards in Britain’s subnormality hospitals include codes of good practice; upgrading of wards to give a more domestic environment; increasing the number of nursing staff responsible for basic residential care; promotion of multidisciplinary decision-making (both clinical and managerial); close liaison with education and social-services departments; an increase in the proportion of N.H.S. funds spent on the mentally handicapped; joint financing schemes whereby N.H.S. money can be used to speed up local-authority developments which complement hospital facilities; inspections under the xgis of the Health Advisory Service; and promotion of public awareness and involvement.
to
Normansfield, the report makes clear, these measures either not in operation or had made little impact. The wards were filthy with even dried faeces in evidence, and rainwater sometimes came through the roof, soaking sleeping patients. No intellectual tour de force, no code of good practice, and no visiting team of experts was needed here to analyse the measures required for improvement. Clearly the defect was in the organisation. Almost every function was being carried out inadequately, and the managers apparently were either powerless or apathetic. The staff at hospital level who requested help from above received no assistance from higher management. Everyone was waiting for someone else to act, whilst morale evaporated, good staff departed, and bitterness and conflict flourished. The important observation from Normansfield is not about the failure of individuals, but the fact that nihilism ran through the whole organisation from wards, to district, to area, to the Department of Health. No-one took useful action-until the day when patients’ lives were endangered by a walk-out of staff. At
were
MANAGERIAL WEAKNESS
Inasmuch as these managers were responsible for many other N.H.S. services and facilities of acceptable quality, how is it that they- appeared so incompetent in this particular sphere? Four possibilities suggest themselves. Firstly, the efforts of top and middle management may have little impact on the standard of clinical and nursing care, this standard being determined solely by clinicians and nurses, or by these staff and other factors such as public demand. Secondly, the 1. Report of the Committee of Inquiry into Normansfield 7357). H. M Stationery Office, 1978. 2. Bavin, J. Nursing Times, 1969, 65, 590
MEDICAL AND NURSING MANPOWER
A word should be said here about the general medical reaction to the Government’s puny efforts to increase priority for mental handicap-"robbing Peter to pay Paul". I doubt whether many of the protesting clinicians are aware of the condition of Paul. I suggest they acquaint themselves with a rundown subnormality hospital, and with the stress suffered by families who cannot bring themselves to allow their handicapped members to enter such facilities. Peter has been robbing Paul for a century, till the latter is destitute. Across the country the standards of mental handicap services vary much more than do those of the acute sector. This is nowhere more obvious than in the sphere of consultant manpower. Some 21% of consultant posts in mental handicap were vacant in England and Wales at the end of September, 1978, and the establishment itself is too low. The training position does not indicate that consultant posts will become easier to fill. The discipline has a bad image, and good career prospects tend to attract third-class opportunists rather than high-quality recruits. Medical schools teach the subject poorly, if at all, and few doctors arrive in the specialty by first, second, or even third choice.
the fanciful notion that a are replaced by residential care staff trained under the Central Council for Education and Training in Social Work-a flight from reality surely without recent rival, and yet another specious claim that professional skills count for nothing. The problems of mental handicap embrace almost the whole gamut of human knowledge, and more, not less professionalism is needed at every point in the system. If the Jay proposals are acted upon we shall return to Bedlam. The
Jay Committee3 propounds
major contribution will be made if nurses
SOLUTIONS
1. At least five professorial departments should be set up in the U.K. and well-endowed so that they can make a major impact on medical recruitment and education at undergraduate and post-graduate levels. 2. The chairs should be held in the first instance by mentalhandicap consultants with a proven record of service-development, teaching ability, and clinical excellence (rather than a good research record).
3. Each academic department should be based on a small service area so that the professorial unit is the population and its mental-handicap services. Financial priority should be used
Hospital (Cmnd. 3. Report of the Committee of Enquiry into Mental Handicap Care. (Cmnd. 7468). H. M. Stationery Office, 1979.
Nursing
and
919
develop these areas of service excellence within, say, five years. 4. Consultant appointments in the areas with poor facilities and recruitment problems should attract automatic C merit awards, and the proportion of A and B awards in the specialty should be increased to that in more popular specialties. to
9. Staff
training
money for
must
be
given high priority.
This
fees, and higher staffing levels for loss of service pensate personnel. more
course
means
to com-
10. All Regional, area, and district teams of officers should be made fully aware of their continuing responsibility for the state of the mental handicap services in their particular sector.
5. Posts for senior administrators and senior nursing officers in mental handicap should also attract substantial inducement
awards.
A STARK CHOICE
planning teams in mental handicap should be the planning bodies for advising district and area management. They should be encouraged to draw up 6. Health-care
given major
status as
5-vear and 10-year plans, and finance should be earmarked D.H.S.S. and regional level (and not allowed to be diverted other uses).
at to
7. Where local authorities are unwilling or unable to develop complementary services, these should be financed through the N.H.S. (Local authorities at present tend to hold up developments on the grounds that they will be unable to carry the cost of joint financed schemes at the end of the take-up period). 8. A.H.A.’s must be pressed to port. They must also accept that dential staff and ancillary help, price of civilised care.
improve administrative suphigh running costs (for resifurniture, clothing) are the
Occasional Book THE DELIGHTS OF EDITING As Miss Maeve O’Connor, senior editor of the Ciba Foundation, London, points out in her excellent book,’ a golden rule for editors is: "work with authors, not against them." A journal editor who is offered thousands of contribuyear may find it impossible to work "with" all the authors who send him their work, so many disappointed would-be contributors may be left with the feeling that the editor is "against" them because he has replied unhelpfully with an unadorned "no", without commenting in detail on the article or suggesting how it might be improved. Miss O’Connor’s book may strike some of her fellow editors as a text for an ideal world which is, for them, a remote paradise peopled by numberless friends with time on their hands and armies of devoted assistant editors. There is no question, however, that she has provided instruction and discussion of much value not only for the newcomer to editing and to journal and book production but also for the gnarled editor who thought he knew it all. Indeed her strictures on those journals which fail to include corrections among their list of contents has already jolted The Lancet into mending its ways. Whenever editors assemble, certain topics are popular for debate, such as speed of publication, how to keep printers up to scratch, how much subediting to undertake, and the editor’s responsibilities in the ethics of experimentation. Miss O’Connor deftly handles these and other editorial chestnuts. Among much else, she also offers guidance on the perilous venture of starting a new journal. The refereeing (or not) of submitted papers can also keep editors talking far into the night, since they are often challenged on their methods of selection. There are those who may take outside advice about only a small proportion of all submissions, though they are more cautious about the papers they actually publish. Such hotheads can find some comfort mistakenly perhaps) in Miss O’Connor’s view that "the ability to choose the best work to publish remains an indefinable and elusive talent owing as much to intuition as to a deep knowledge of the subject". tions a
1
Scientific Books and Wells Pitman Medical 1978.
Editing
Journals. By Pp. 218. £7.
MAEVE O’CONNOR.
Tunbndge
to these measures can be financial, that we prefer to buy something else. Apalling conditions will continue in Britain’s subnormality hospitals until the Government, through the D.H.S.S., invigorates clinical and managerial leadership. There should be no more major inquiries, since these are unfair to the scapegoats at local level, ineffective in providing solutions, and wasteful of money and effort. In the meantime the present dedicated staff who continue to look after this rejected population should be publicly assured that the present neglect is not theirs. We have a stark choice-a major shift of resources towards mental handicap, or a continuation of social euthanasia, for which we all bear a measure of responsibility.
The which
only objection means
A few medical journals continue to publish unsigned editorials (and book reviews)-a practice for which their editors are regularly rebuked. After examining the pros and cons of anonymity in editorials, Miss O’Connor much prefers them to be signed, though again there is a hint of solace for the miscreants in her concession that anonymity can sometimes be tolerated-for example, so that "younger or less well-known scientists" may be given "an opportunity to speak freely without fear of being harmed in their careers or having their views discounted because readers have not heard of the writer before". She does not mention one of the arguments in favour of unsigned editorials: some scientific journals act in part as newspapers and commentators and they shamelessly declare that their role includes the expression of an editorial opinion. If The Times ever returns should its editorials be signed? Miss O’Connor would draw a distinction between editorials on scientific subjects by outside advisers (which should be signed) and editorials by the editor and his staff (unsigned). But there remains the question "when is an editorial an editorial?" For some old-fashioned editors, a signed editorial is not an editorial : it is a commissioned article by whoever’s name appears on it; and the editor may distinguish it by some fanciful title, such as "occasional survey" or "regular review", but he should not call it an editorial. Looking to the future, Miss O’Connor does not foresee the early decline of today’s style of scientific journals in the face of the impact of new techniques and the coming of the paperless world. Electronic journals will be more widely used, but paper journals will, she believes, exist side by side with the evolving species for a long time yet. The new era may show its talents not so much in replacing paper books and journals but in reducing their costs, speeding their publication, and improving their production and distribution. Among the ten appendices are guidelines for authors, a checklist for handling of manuscripts when they are received in an editorial office, the B.M.]. code of advertisement policy, and guidelines for book reviewers (to which this particular review, alas, seldom conforms). The book’s acknowledgments refer to the contribution of Dr F. Peter Woodford, "who wrote most of the first draft and provided critical guidance on much of the second. He is a co-author in fact if not in appearance on the title page, and but for the pressures of his other work he would have been named as the first author of this book".
ANON.ED.
problems to
Points of View
AFTER NORMANSFIELD—WHAT NEXT?
ment.
JACK BAVIN Twyver Unit, Coney Hill Hospital,
Gloucester GL4
7QJ
The last three factors seem to be all-important. In this where a huge effort needs to be made to provide and maintain an acceptable standard of care and treatment, the endeavours of middle and top management are crucial: nothing but a major input of managerial talent and of money will do anything but scratch the surface of the problem.
sphere, THE Normansfield Report! has not received the debate it merits. It is the latest in a series of reports documenting medical, nursing, and administrative failure to deliver a tolerable standard of treatment to longstay populations of mentally handicapped people. Normansfield presents us with a picture of a National Health Service hospital with a demoralised staff providing minimal services to keep alive in a degrading state a number of helpless handicapped people-a process which ten years ago I termed social euthanasia.2 The remedies which have been proposed and implemented raise standards in Britain’s subnormality hospitals include codes of good practice; upgrading of wards to give a more domestic environment; increasing the number of nursing staff responsible for basic residential care; promotion of multidisciplinary decision-making (both clinical and managerial); close liaison with education and social-services departments; an increase in the proportion of N.H.S. funds spent on the mentally handicapped; joint financing schemes whereby N.H.S. money can be used to speed up local-authority developments which complement hospital facilities; inspections under the xgis of the Health Advisory Service; and promotion of public awareness and involvement.
to
Normansfield, the report makes clear, these measures either not in operation or had made little impact. The wards were filthy with even dried faeces in evidence, and rainwater sometimes came through the roof, soaking sleeping patients. No intellectual tour de force, no code of good practice, and no visiting team of experts was needed here to analyse the measures required for improvement. Clearly the defect was in the organisation. Almost every function was being carried out inadequately, and the managers apparently were either powerless or apathetic. The staff at hospital level who requested help from above received no assistance from higher management. Everyone was waiting for someone else to act, whilst morale evaporated, good staff departed, and bitterness and conflict flourished. The important observation from Normansfield is not about the failure of individuals, but the fact that nihilism ran through the whole organisation from wards, to district, to area, to the Department of Health. No-one took useful action-until the day when patients’ lives were endangered by a walk-out of staff. At
were
MANAGERIAL WEAKNESS
Inasmuch as these managers were responsible for many other N.H.S. services and facilities of acceptable quality, how is it that they- appeared so incompetent in this particular sphere? Four possibilities suggest themselves. Firstly, the efforts of top and middle management may have little impact on the standard of clinical and nursing care, this standard being determined solely by clinicians and nurses, or by these staff and other factors such as public demand. Secondly, the 1. Report of the Committee of Inquiry into Normansfield 7357). H. M Stationery Office, 1978. 2. Bavin, J. Nursing Times, 1969, 65, 590
MEDICAL AND NURSING MANPOWER
A word should be said here about the general medical reaction to the Government’s puny efforts to increase priority for mental handicap-"robbing Peter to pay Paul". I doubt whether many of the protesting clinicians are aware of the condition of Paul. I suggest they acquaint themselves with a rundown subnormality hospital, and with the stress suffered by families who cannot bring themselves to allow their handicapped members to enter such facilities. Peter has been robbing Paul for a century, till the latter is destitute. Across the country the standards of mental handicap services vary much more than do those of the acute sector. This is nowhere more obvious than in the sphere of consultant manpower. Some 21% of consultant posts in mental handicap were vacant in England and Wales at the end of September, 1978, and the establishment itself is too low. The training position does not indicate that consultant posts will become easier to fill. The discipline has a bad image, and good career prospects tend to attract third-class opportunists rather than high-quality recruits. Medical schools teach the subject poorly, if at all, and few doctors arrive in the specialty by first, second, or even third choice.
the fanciful notion that a are replaced by residential care staff trained under the Central Council for Education and Training in Social Work-a flight from reality surely without recent rival, and yet another specious claim that professional skills count for nothing. The problems of mental handicap embrace almost the whole gamut of human knowledge, and more, not less professionalism is needed at every point in the system. If the Jay proposals are acted upon we shall return to Bedlam. The
Jay Committee3 propounds
major contribution will be made if nurses
SOLUTIONS
1. At least five professorial departments should be set up in the U.K. and well-endowed so that they can make a major impact on medical recruitment and education at undergraduate and post-graduate levels. 2. The chairs should be held in the first instance by mentalhandicap consultants with a proven record of service-development, teaching ability, and clinical excellence (rather than a good research record).
3. Each academic department should be based on a small service area so that the professorial unit is the population and its mental-handicap services. Financial priority should be used
Hospital (Cmnd. 3. Report of the Committee of Enquiry into Mental Handicap Care. (Cmnd. 7468). H. M. Stationery Office, 1979.
Nursing
and
919
develop these areas of service excellence within, say, five years. 4. Consultant appointments in the areas with poor facilities and recruitment problems should attract automatic C merit awards, and the proportion of A and B awards in the specialty should be increased to that in more popular specialties. to
9. Staff
training
money for
must
be
given high priority.
This
fees, and higher staffing levels for loss of service pensate personnel. more
course
means
to com-
10. All Regional, area, and district teams of officers should be made fully aware of their continuing responsibility for the state of the mental handicap services in their particular sector.
5. Posts for senior administrators and senior nursing officers in mental handicap should also attract substantial inducement
awards.
A STARK CHOICE
planning teams in mental handicap should be the planning bodies for advising district and area management. They should be encouraged to draw up 6. Health-care
given major
status as
5-vear and 10-year plans, and finance should be earmarked D.H.S.S. and regional level (and not allowed to be diverted other uses).
at to
7. Where local authorities are unwilling or unable to develop complementary services, these should be financed through the N.H.S. (Local authorities at present tend to hold up developments on the grounds that they will be unable to carry the cost of joint financed schemes at the end of the take-up period). 8. A.H.A.’s must be pressed to port. They must also accept that dential staff and ancillary help, price of civilised care.
improve administrative suphigh running costs (for resifurniture, clothing) are the
Occasional Book THE DELIGHTS OF EDITING As Miss Maeve O’Connor, senior editor of the Ciba Foundation, London, points out in her excellent book,’ a golden rule for editors is: "work with authors, not against them." A journal editor who is offered thousands of contribuyear may find it impossible to work "with" all the authors who send him their work, so many disappointed would-be contributors may be left with the feeling that the editor is "against" them because he has replied unhelpfully with an unadorned "no", without commenting in detail on the article or suggesting how it might be improved. Miss O’Connor’s book may strike some of her fellow editors as a text for an ideal world which is, for them, a remote paradise peopled by numberless friends with time on their hands and armies of devoted assistant editors. There is no question, however, that she has provided instruction and discussion of much value not only for the newcomer to editing and to journal and book production but also for the gnarled editor who thought he knew it all. Indeed her strictures on those journals which fail to include corrections among their list of contents has already jolted The Lancet into mending its ways. Whenever editors assemble, certain topics are popular for debate, such as speed of publication, how to keep printers up to scratch, how much subediting to undertake, and the editor’s responsibilities in the ethics of experimentation. Miss O’Connor deftly handles these and other editorial chestnuts. Among much else, she also offers guidance on the perilous venture of starting a new journal. The refereeing (or not) of submitted papers can also keep editors talking far into the night, since they are often challenged on their methods of selection. There are those who may take outside advice about only a small proportion of all submissions, though they are more cautious about the papers they actually publish. Such hotheads can find some comfort mistakenly perhaps) in Miss O’Connor’s view that "the ability to choose the best work to publish remains an indefinable and elusive talent owing as much to intuition as to a deep knowledge of the subject". tions a
1
Scientific Books and Wells Pitman Medical 1978.
Editing
Journals. By Pp. 218. £7.
MAEVE O’CONNOR.
Tunbndge
to these measures can be financial, that we prefer to buy something else. Apalling conditions will continue in Britain’s subnormality hospitals until the Government, through the D.H.S.S., invigorates clinical and managerial leadership. There should be no more major inquiries, since these are unfair to the scapegoats at local level, ineffective in providing solutions, and wasteful of money and effort. In the meantime the present dedicated staff who continue to look after this rejected population should be publicly assured that the present neglect is not theirs. We have a stark choice-a major shift of resources towards mental handicap, or a continuation of social euthanasia, for which we all bear a measure of responsibility.
The which
only objection means
A few medical journals continue to publish unsigned editorials (and book reviews)-a practice for which their editors are regularly rebuked. After examining the pros and cons of anonymity in editorials, Miss O’Connor much prefers them to be signed, though again there is a hint of solace for the miscreants in her concession that anonymity can sometimes be tolerated-for example, so that "younger or less well-known scientists" may be given "an opportunity to speak freely without fear of being harmed in their careers or having their views discounted because readers have not heard of the writer before". She does not mention one of the arguments in favour of unsigned editorials: some scientific journals act in part as newspapers and commentators and they shamelessly declare that their role includes the expression of an editorial opinion. If The Times ever returns should its editorials be signed? Miss O’Connor would draw a distinction between editorials on scientific subjects by outside advisers (which should be signed) and editorials by the editor and his staff (unsigned). But there remains the question "when is an editorial an editorial?" For some old-fashioned editors, a signed editorial is not an editorial : it is a commissioned article by whoever’s name appears on it; and the editor may distinguish it by some fanciful title, such as "occasional survey" or "regular review", but he should not call it an editorial. Looking to the future, Miss O’Connor does not foresee the early decline of today’s style of scientific journals in the face of the impact of new techniques and the coming of the paperless world. Electronic journals will be more widely used, but paper journals will, she believes, exist side by side with the evolving species for a long time yet. The new era may show its talents not so much in replacing paper books and journals but in reducing their costs, speeding their publication, and improving their production and distribution. Among the ten appendices are guidelines for authors, a checklist for handling of manuscripts when they are received in an editorial office, the B.M.]. code of advertisement policy, and guidelines for book reviewers (to which this particular review, alas, seldom conforms). The book’s acknowledgments refer to the contribution of Dr F. Peter Woodford, "who wrote most of the first draft and provided critical guidance on much of the second. He is a co-author in fact if not in appearance on the title page, and but for the pressures of his other work he would have been named as the first author of this book".
ANON.ED.